Drug&ETOH Flashcards
1
Q
What is the precontemplation stage of Prochaska and DiClemte’s stages of change model?
A
There is no interest in change in the foreseeable future
2
Q
What is the contemplation stage of Prochaska and DiClemte’s stages of change model?
A
Change may be considered in the next 1-6 months
3
Q
What is the preparation stage of Prochaska and DiClemte’s stages of change model?
A
Change is planned in the next month
4
Q
What is the action stage of Prochaska and DiClemte’s stages of change model?
A
Meaningful changes has been made in last month
5
Q
What is the maintenance stage of Prochaska and DiClemte’s stages of change model?
A
Changes are maintained for 6 months or more
6
Q
If a pregnant woman decides to withdraw from heroin/opiates which trimester should she do it?
A
2nd trimester (1st trimester = high risk of miscarriage, 3rd trimester = high risk of prematurity)
7
Q
Which medication is recommended for use in opiate withdrawal in pregancy?
A
Methadon
8
Q
What does the FRAMES acronym stand for?
A
Feedback of risks Responsibility highlighted Advised to abstain/cut down Menu of alternative options/activities offered Empathic interviewing Self-efficacy enhanced regularly
(features of effective brief interventions for substance use)
9
Q
Which symptoms would someone with heroin dependence not develop tolerance to?
A
Constipation
Miosis
10
Q
What are the effects of LSD?
A
- heightening of perception
- distortion of shape
- intensification of colour and sound
- apparent movement of stationary objects
11
Q
Do you get physical withdrawal symptoms from LSD?
A
No
12
Q
What type of hallunications are present in amphetamine intoxication?
A
visual
13
Q
is there any benefit of supervised injectable heroin/methadone over optimised oral methadone in health and social outcomes?
A
No
14
Q
What are somee of the complications of chronic use of khat?
A
- hallucinations
- impaired inhibition
- diminished sexual drive
- psychosis
- increased risk of MI
- increased risk of oral cancer
- increase in suicidal ideation
15
Q
What are the acute effects of khat?
A
Similar to amphetamines:
- euphoria
- excitement
- loss of appetite
16
Q
Which medications can help with strong cravings in alcohol abstinence (especially after if there has already been one relapse)?
A
Naltrexone (opioid antagonist)
Nalmefene (opioid receptor modulator) - PRN
17
Q
Length of time that phencyclidine can be detected in a urine drug screen
A
8 days
18
Q
Length of time that MDMA/ecstacy can be detected in a urine drug screen
A
48 hours
19
Q
Length of time that amphetamine can be detected in a urine drug screen
A
48 hours
20
Q
Length of time that LSD can be detected in a urine drug screen
A
24 hours
21
Q
What are the signs of phencyclidine (PCP) intoxiation?
A
violent behavior
nystagmus
tachycardia
hypertension
anesthesia
analgesia
Impaired motor function
Dysarthria
Hallucinations, delusions, paranoia
Depression
Synaesthesia
22
Q
What is phencyclidine (PCP)?
A
Dissociative anaesthetic agent
NMDA receptor antagonist
23
Q
What is 3,4-Methylenedioxymethamphetamine (ecstacy/MDMA)?
A
Serotonin neurotoxin
-produces stimulant and mild hallucinogenic effects
24
Q
Does tolerance develop with MDMA?
A
Yes, subsequent doses have less potensy
25
What is LSD?
5-HT2A agonist and most potent hallucinogen
26
Which drugs have no recognised withdrawal syndromes?
ketamine and LSD
27
How quick is the onset of the "trip" with LSD?
Very quick ~15 mins orally which is why it is uncommon to inject
28
Early signs of opioid withdrawal
```
Agitation/restlessness
Yawning
Muscle aches
Sweating
Anxiety
Increased tearing
Runny nose
```
29
Late signs of opioid withdrawal (trainspotting)
```
Insomnia
Vomiting
Dilated pupils
Diarrhoea
Nausea
Piloerection
-->
followed by tachycardia, increase in respiratory rate and abdominal cramps
```
Advanced sign of opioid withdrawal = muscle spasm
30
Signs of cannabis withdrawal
- Insomnia
- reduced appetite
- irritability
31
Nick Cave opiate intoxication
Euphoria, constricted pupils then drowsy, constipated then goes into respiratory depression, pupillary constriction
32
Cocaine + amphetamine intoxication
| Alex Harding on night out
Initially increased energy, hyperactivity, diaphoresis euphoria, heightened self-esteem
Gets paranoid (vsual hallucinations)
Sensation of bugs crawling beneath the skin (formication)
Arrythmias and tachycardia
Goes home but doesn't stop for food due to reduced appetite and nausea
Doesn't sleep due to insomnia
33
Cocaine + amphetmaine withdrawal
| Alex Harding after night out
```
Feels depressed
Hypersomnia and vivid dreams
Increased appetite (insatiable)
When awake irritable, anxious and agitated
Headache
```
34
MDMA/ecstasy
| Miley Cyrus - Molly
```
Increased energy
Increase in empathy and extroversionn
Accelerated thinking
Euphoria
Really sociable and increased response to touch
Increased sweating
Jaw clenching
Increasead nausea and vomiting
Increased libido
Deaths asociated with dehydration annd hyperthermia
```
35
MDMA withdrawal
| Miley Cyrus Slide Away video
```
Depersonalisation
Derealisation
Depression
Insomnia
Anxiety
Difficulty concentrating
Fatigue
Loss of appetite/anorexia
```
36
```
Cannabis intoxication
(Killer Mike)
```
```
Relaxation
Intensified sensory experience
Red eyes
Paranoia / anxiety
Increased appetite
Dry mouth
```
37
Cannabis withdrawal
| Killer Mike Living Black
Insomnia (on park bench)
Reduced appetite couldn't eat
Irritable
38
LSD
| Khyle in Boogie Shed
```
Pupil dilation
Sweaty
Tachy
Palpitations, tremors
Incoordination dancing badly
Perceptual changes
-shape distortion
-stationary things are moving like the bar
-intense colours and sounds
```
39
Ketamine intoxication
| The Weeknd I can't feel my face
```
Euphoria
Dissociation
Hallucinations
Muscle rigidity
Ataxia
```
Staggering around, face has rigid muscles feels amazing
40
Which pharmacological option is most suitable for managing cannabis withdrawal?
Benzos
41
Increased need for handling in babies is seen in withdrawal of which drug?
Nictotine
42
In Korsakoff's psychosis which memory test will NOT be impaired?
Digit span
43
Severe personality disorder is a contraindication for the use of which drug used in addiction psychiatry?
Benzos
44
What's the traid of Wernicke's?
Wernicke's encephalopathy is characterised by the triad of global confusion, ophthalmoplegia, and ataxia (classic triad only present in 10% of people)
45
Apart from alcohol dependency in which other scenarios might patients develop Wernicke's?
Anorexia nervosa
Following gastric surgery
Malignancy
AIDS
Hyperemesis gravidarum
Prolonged total parenteral nutrition
46
What's the associated mortality of Wernicke's?
mortality of 10-20%.
47
Where are the lesions of Werncike's?
The lesions (gliosis and small haemorrhages) of Wernicke's encephalopathy occur in a symmetrical distribution in structures surrounding the third ventricle, aqueduct, and fourth ventricle. The mammillary bodies are involved in up to 80% of cases, atrophy of these structures is specific for Wernicke's encephalopathy.
Other affected sites include the hypothalamus, mediodorsal thalamic nucleus, colliculi and midbrain tegmentum.
48
Of those with Wernicke's who are interested what % go on to develop Korsakoff?
Of those untreated, 80% go on to develop Korsakoff's syndrome.
49
What should be avoided when thiamine deficiency is suspected as it can precipitate or exacerbate Wernicke's?
IV glucose (thiamine replacement but be given first)
50
What's the treatment of Wernicke's?
IM/IV Pabrinex >500mg for 3-5 days (2 pairs TDS for 3 days then 1 pair TDS for 2 days)
51
What are the class A drugs?
Cocaine, crack, ecstasy, LSD, magic mushrooms, heroin, methamphetamine, and any injected class B substance
52
What's the maximum prison sentence associated with class A drugs?
7 years
53
What are the class B drugs?
Cannabis, amphetamine, codeine, barbiturates, phoclonidime, ketamine, methylphenidate, synthetic cannabinoids, synthetic cathinones (eg mephedrone, methoxetamine)
54
Whats the maximum prison sentence associated with class B drugs?
5 years
55
What are the class C drugs?
Anabolic steroids, minor tranquillizers (benzodiazepines), gamma hydroxybutyrate (GHB), gamma-butyrolactone (GBL), piperazines (BZP - stimulant like legal high), khat
56
What's the maximum prison sentence associated with class C drugs?
2 years
57
Which drug interferes with the conversion of aldehyde to acetic acid?
Disulfram
58
What's the mechanism of action of disulfram?
binding irreversibly to aldehyde dehydrogenase
results in accumulation of acetyl acetaldehyde which causes flushing, nausea, vomiting, headache, tachycardia and palpitations when alcohol is consumed
59
How long does it take for symptoms to begin after drinking alcohol when taking Disulfram?
Symptoms start 5-15 minutes after drinking alcohol and last for several hours producing symptoms of nausea and headache.
60
What's the class of Acamprosate?
Acamprosate is a structural analogue of gamma-aminobutyric acid (GABA)
It acts in a dose dependent fashion
61
What is the most common adverse effect varenicline?
Nausea
62
What's the duration of NRT for most people maintaining abstinence from cigarettes?
For most people maintaining abstinence from cigarettes, the duration of treatment with NRT is 8-12 weeks (depending on which form of NRT is used and which dose is initiated), followed by a gradual reduction in dose.
63
When should Bupropion and Vareniciline be initiated in smoking cessation?
While the person is still smoking. The person must start Bupropion 7 days before stopping smoking.
64
When should Bupropion be avoided in smoking cessation?
Bupropion should be avoided in the following:
adolescents
pregnancy and breast feeding
history of bipolar disorder
Contraindicated in:
epilepsy
eating disorders
65
What's the length of the usual course of Bupropion in smoking cessation?
After a usual course of 8 weeks, discontinuation reactions are unlikely and bupropion can be stopped without tapering the dose.
66
What are common side effects of Bupropion?
The most common adverse effects of bupropion include dry mouth, gastrointestinal disturbances, insomnia (which can be reduced by not giving the last dose at bedtime), headache, impaired concentration, and dizziness.
67
What's the recommended course length of Vareniciline for smoking cessation?
The recommended course of treatment is 12 weeks
68
When should Vareniciline be avoided?
epilepsy
pregnancy and breast feeding
significant renal impairment
69
What is the lifetime prevalence of suicide in alcohol dependence?
7%
70
Whats the increased risk of developing Schizophrenia with regular cannabis use pre 15 years old?
People are 4.5 times more likely to be schizophrenic at 26 if they were regular cannabis smokers at 15, (than general population)
compared to 1.65 times for those who did not report regular use until age 18 (than general population)
71
Whats the increased risk of developing Schizophrenia with regular cannabis use?
2x
72
What very rare condition has IV heroin use been associated with (more in black men?)
Intravenous heroin use has been associated with nephropathy (very rare) probably mediated by bacterial infection. Heroin associated nephropathy is usually seen in African-American men (reasons unknown).
73
When do signs of alcohol withdrawal begin? And then do they peak?
The initial signs and symptoms of withdrawal begin from 6 to 48 hrs after drinking stops. They usually peak between 10-30 hours
74
What are the symptoms of alcohol withdrawal?
Sweating, agitation, nausea, tremor, irritability, and in a small number of cases transient hallucinations. These initial symptoms usually diminish by 48hrs.
75
Which percentage of people undergoing withdrawal experience delirium tremens?
5%
76
Whats the mortality rate of delirium tremens?
1-5%
77
How long after alcohol cessation does delirium tremens occur?
2-4 days
78
What are the risk factors for delirium tremens?
abnormal liver function, old age, severity of withdrawal symptoms, concurrent medical illness, and heavy alcohol use.
79
What's the treatment for alcohol withdrawal?
Benzos
80
What is Suboxone?
Suboxone is a combination of four parts buprenorphine to one part naloxone. The latter is added to prevent addicts from injecting the tablets, as this was common when addicts were given pure buprenorphine tablets. Because it contains naloxone it is likely to produce intense withdrawal symptoms if injected, this does not occur when the tablet is swallowed as naloxone is not absorbed by the gut.
81
The legal high known as Mephedrone (Mcat) is most similar to what drug?
Ecstasy + amphetamines
| It is chemically similar to cathinone, the active ingredient of the African Khat
82
What is the appearance and smell of Mephedrone/Mcat?
It can have a distinctive odour, reported to range from a synthetic fishy smell to the smell of vanilla and bleach, stale urine, or electric circuit boards.
83
What class of drug is Mephedrone?
Class B
84
Which drug does the legal high Piperazines mimic?
Ecstasy
85
What class of drug is Piperazine?
Class B
86
What's the effect of the legal high GBL (gammabutyrolactone)?
euphoric, sedative, and anabolic effects (used in bodybuilding).
87
What class of drug is GBL?
Class C
88
What drug are Benzofuran compounds similar to?
Ecstacy
89
What class of drug do Benzofuran compounds belong to?
Class B
90
Ibuprofen is known to cause false positive results when testing for which illicit substance?
Cannabis
91
Which drugs can cause a positive cannabis result on urine drug screen?
NSAIDS
| PPIs
92
Which drugs can cause a positive amphetamine result on urine drug screen?
Amantadine, penicillin, bupropion, ephedrine, phenothiazines, ranitidine, selegiline, trazodone, methylphenidate, phenylephrine
93
Which drugs can cause a positive benzo result on urine drug screen?
Sertraline
94
Which drugs can cause a positive cocaine result on urine drug screen?
Topical anaesthetics
95
Which drugs can cause a positive opioid result on urine drug screen?
Codeine containing preparations (e.g. Cough mixture), poppy seeds, verapamil, tonic water
96
Which methods are there for drug testing?
Drug testing can be done by the following methods:-
Urine
Oral fluid
Blood
Hair
Sweat
97
What's the focus of motivational interviewing?
focuses on exploring and resolving ambivalence and centers on the motivational process that facilitates change
98
Who introduced motivational interviewing and when?
introduced by William Miller in 1983
99
What are the three key elements motivational interviewing is based on?
and is based on three key elements:-
Collaboration (rather than confrontation)
Evocation (drawing out rather than imposing ideas)
Autonomy (rather than authority)
100
What are the 4 principles of motivational interviewing?
Express empathy (see it from the client perspective)
Support self-efficacy (be positive and recognise previous successes and strengths)
Roll with resistance (be impartial and avoid conflict)
Develop discrepancy (help client see the discrepancy between current circumstances and future goals)
101
What is change talk in motivational interviewing?
Change talk is defined as statements by the client that reveals consideration of, motivation for, or commitment to change
102
What are types of change talk?
D - Desire (to change)
A - Ability (client recognising they can change)
R - Reason (client understands why change is needed)
N - Need (client believes they need to change)
C - Commitment (client intends to change)
A - Activation (client is ready, prepared and willing to change)
T - Taking steps (client is taking steps towards change)
103
What is the method of choice for detecting alcohol dependence in primary care?
AUDIT
104
AUDIT screening tool overview
10 item questionnaire
Takes about 2-3 minutes to complete
Has been shown to be superior to CAGE and biochemical markers for predicting alcohol problems
Minimum score = 0, maximum score = 40
A score of 8 or more in men, and 7 or more in women, indicates a strong likelihood of hazardous or harmful alcohol consumption
A score of 15 or more in men, and 13 or more in women, is likely to indicate alcohol dependence
AUDIT-C is an abbreviated form consisting of 3 questions
105
FAST screening overview
4 item questionnaire
Minimum score = 0, maximum score = 16
The score for hazardous drinking is 3 or more
With relation to the first question 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits
If the answer to the first question is 'never' then the patient is not misusing alcohol
If the response to the first question is 'Weekly' or 'Daily or almost daily' then the patient is a hazardous, harmful or dependent drinker. Over 50% of people will be classified using just this one question
106
Questions asked in FAST screen?
1. MEN: How often do you have EIGHT or more drinks on one occasion?
WOMEN: How often do you have SIX or more drinks on one occasion?
2. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
3. How often during the last year have you failed to do what was normally expected of you because of drinking?
4. In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?
107
CAGE questions
C Have you ever felt you should Cut down on your drinking?
A Have people Annoyed you by criticising your drinking?
G Have you ever felt bad or Guilty about your drinking?
E Have you ever had a drink in the morning to get rid of a hangover (Eye opener)?
108
What's a positive score on CAGE?
2 or more
109
Which alcohol screening tool was developed for use in a busy A&E department to detect hazardous drinking?
PAT (Paddington Alcohol Test),.
110
RAPS4 screen
R (remorse)Have you had a feeling of guilt or remorse after drinking?
A (amnesia)Has a friend or a family member ever told you about things you said or did while you were drinking that you could not remember?
P (performance)Have you failed to do what was normally expected of you because of drinking?
S (starter drinker behaviour)Do you sometimes take a drink when you first get up in the morning?
A 'yes' answer to at least one of the four questions suggests that your drinking is harmful.
111
What's SASQ screening tool?
SASQ (Single alcohol screening questionnaire), asks only one question, when was the last time you had more than x alcoholic drinks in one day? (Where x is 8 for men and 6 for women). An answer of within 3 months indicates harmful or hazardous drinking
112
Which medication is effective in alcohol withdrawal is advised against as it carries a high risk of respiratory depression?
Clomethiazole (heminevrin)
113
What's the treatment of choice for associated hallucinations in alcohol withdrawal?
For associated hallucinations, haloperidol is the treatment of choice
114
Cannabis (heavy use) lasts in urine for?
14-28 days
115
Cannabis (single use) lasts in urine for?
3 days
116
Alcohol lasts in urine for?
12 hours
117
Standard drugs included in a urinalysis screen include?
Cannabis
Amphetamine
Cocaine
Methadone
Benzodiazepines
Opiates
118
According to the UK Department of Health, what quantity of alcohol is considered safe to consume during pregnancy?
None
119
What's the risk of drinking alcohol in the first 3 months of pregnancy?
increased risk of miscarriage
120
What does NICE say about drinking in pregnancy?
Women should be advised that if they choose to drink alcohol while they are pregnant they should drink no more than 1-2 UK units once or twice a week.
121
The Department of Health currently recommends weekly safe drinking limits of what for men and women?
14 U for men and 14 U for women
122
Which type of amnesia is characteristic of Korsakoff's syndrome?
Korsakoff's syndrome results in anterograde amnesia
123
Whats the most reliable indicator of recent alcohol use
GGT is the most reliable indicator of recent alcohol use
124
What are the nice guidelines for opioid detox?
The NICE Guidelines on Opioid Detoxification make the following general recommendations.
Methadone (opioid agonist) or buprenorphine (partial agonist at the µ opioid receptor) should be offered as the first-line treatment in opioid detoxification.
Alternatives include: alpha-2 adrenergic agonists e.g. clonidine and lofexidine
Ultra-rapid detoxification under general anaesthesia or heavy sedation (where the airway needs to be supported) must not be offered.
125
Which drugs are are licensed as substitute opioids for the management of opioid dependence?
In the UK, only methadone and buprenorphine are licensed as substitute opioids for the management of opioid dependence
126
Which drug is licensed for symptomatic relief during opioid detoxification?
In addition, lofexidine is licensed for symptomatic relief during opioid detoxification
127
What's the goal of opioid maintenance therapy?
The goal of maintenance therapy is harm reduction and stabilization of lifestyle.
128
Symptoms of alcohol intoxication
Poor concentration
Impaired reaction times
Conjunctival injection
Pinpoint pupils
Poor coordination
Memory difficulties
Impaired judgement
Impaired sense of time and space
129
What was Project MATCH?
studied which types of alcoholics respond best to which forms of treatment. Three types of treatment were investigated:-
Cognitive Behavioural Coping Skills Therapy, focusing on correcting poor self-esteem and distorted, negative, and self-defeating thinking.
Motivational Enhancement Therapy, which helps clients to become aware of and build on personal strengths that can help improve readiness to quit.
Twelve-Step Facilitation Therapy administered as an independent treatment designed to familiarize patients with the AA philosophy and to encourage participation.
130
What was the conclusion of Project MATCH?
It found that the three psychological therapies tested were equal in effectiveness
131
What is the most effective way to reducing alcohol related harm?
Making alcohol less affordable
132
Which medical problem presenting with painful haematuria can chronic ketamine use cause?
There are case reports of chronic ketamine use causing ulcerative cystitis
133
What is the maximum duration that benzodiazepines should be prescribed for anxiety according to Maudsley Guidelines?
4 weeks
134
What are the physical withdrawal symptoms from benzos?
```
Stiffness
Weakness
GI disturbance
Paraesthesia
Flu-like symptoms
Visual disturbance
```
135
What are the psychological withdrawal symptoms from benzos?
```
Anxiety
Insomnia
Nightmares
Depersonalisation
Decreased memory and concentration
Delusions and hallucinations
Depression
```
136
What should be done for patients on short acting benzodiazepines who are keen to withdraw from them?
Patients on short acting benzodiazepines who are keen to withdraw from them should first be converted to diazepam. This is due to the fact that diazepam has a longer half-life and so tends to produce less severe withdrawal.
137
Equivalent doses of 10mg diazepam
```
Lorazepam1mg
Lormetazepam1mg
Nitrazepam10mg
Oxazepam30mg
Temazepam20mg
Chlordiapoxide25mg
```
138
What's a psychiatric side effect of Vareniciline?
Patients using varenicline are at an increased risk of suicidal thoughts
Excercebates underlying psych illness including depression
139
Which is more effective Vareniciline or Bupropion?
Vareniciline
140
The FDA issued what safety announcement about varenicline
may be associated with a small, increased risk of certain cardiovascular adverse events in patients who have cardiovascular disease.
141
Which of the following is indicated in the management of problem gambling associated with impulse control disorders?
Naltrexone
142
What pharmacological management options are there for problem gambling?
Trials have shown that selective serotonin reuptake inhibitors (SSRIs), naltrexone and mood stabilisers are all effective, although none has demonstrated superiority over others.
143
What is true of alcoholic hallucinosis?
Occurs in clear consciousness
144
What is alcoholic hallucinosis?
- AKA Alcohol induced psychotic disorder
- unstructured auditory or visual hallucinations that occur either during or after a period of heavy alcohol consumption
- Lasts less than one week.
- Good response to antipsychotics
145
What is Marchiafava-Bignami disease?
Rare disorder (250 cases total) seen in those with alcoholism and malnutrition (M>F).
First described in 1898 in Italian red wine drinkers
Patients often present with non specific clinical features such as a motor or cognitive disturbance (dementia, spasticity, dysarthria, gait changes). It is characterised by progressive demyelination and subsequent necrosis of the corpus callosum and adjacent subcortical white matter.
146
How long does home detoxification from alcohol usually take?
Home detoxification is usually complete within 5-9 days
147
When is inpatient alcohol detox preferred?
Inpatient detox is preferred when there is:
- high risk of seizures or DT (past incidence, present symptoms or high mean cell volume)
- psychiatric morbidity (suicide risk)
- debilitating physical health problem
- Wernicke's/Korsakoff's
- homelessness or social difficulties
148
What's the most common ocular abnormality seen in Wernicke's?
- Nystagmus (usually horizontal) is the most common ocular abnormality seen in Wernicke's (see in 85% of cases)
- Others include bilateral 6th nerve palsy, conjugate gaze palsy, pupillary abnormalities, retinal haemorrhage, ptosis, scotomata
- In general eye signs are usually bilateral but not symmetrical
149
By how many times is a person with a first degree relative with alcohol dependence likely to develop the same condition when compared to a person with no family history?
4x
150
According to the ICD-10 how many criteria of craving, tolerance, and withdrawal does the patient need to have to receive a diagnosis of dependency?
3
151
Criteria for alcohol dependence syndrome according to ICD 10 - how many needed to score and present for how long?
Compulsion
Loss of control
Physiological withdrawal
use of alcohol to relieve from withdrawal symptoms
Tolerance
Neglect of rest of life
Persistence despite clear evidence of harmful consequence
152
What are Edwards and Gross criteria for alcohol dependence?
```
Edwards and Gross criteria
Narrowing of the drinking repertoire
Salience (prominence) of drink seeking behaviour
Tolerance
Withdrawal symptoms
Relief of withdrawal by further drinking
Compulsion to drink
Rapid reinstatement of symptoms after a period of abstinence
```
153
Which aspect of memory is most severely affected in the Korsakoff syndrome?
Episodic
154
Opioid detoxification should not be routinely offered to?
With a medical condition needing urgent treatment.
In police custody, or serving a short prison sentence or a short period of remand, consideration should be given to treating opioid withdrawal symptoms with opioid agonist medication.
Who have presented to an acute or emergency setting, the primary emergency problem should be addressed and opioid withdrawal symptoms treated, with referral to further drug services as appropriate.
155
What's Pellagra caused by?
Pellagra is caused by a deficiency of vitamin B3 (niacin).
156
What are the three Ds of Pellagra?
Pellagra is classically defined by 'the three Ds':-
Diarrhoea
Dermatitis
Dementia
157
Dependence to what can result in pellagra?
Alcohol
158
What s the most common symptom of benzodiazepine withdrawal?
Insomnia is the most common symptom of benzodiazepine withdrawal.
159
Which of the following is not covered under the Misuse of Drugs Act 1971?
Amyl nitrite (poppers)
160
According to the National Treatment Outcomes Research Study (NTORS), what is the most common crime in those with drug dependence?
Shoplifting
161
What % of offender with alcohol dependence account for the majority of crimes committed?
10% of offenders account for 76% of the crimes
162
How long do the NICE guidelines suggest a period of inpatient opioid detoxification should take?
4 weeks
163
What is the most common presenting feature of Wernicke's encephalopathy?
Ataxia
164
The effects of oral methadone last for
12-24 hours
165
The highest levels of binge drinking occur in which age group?
The highest levels of binge drinking occur in people aged 16-24
166
Binge drinking prevalence
21% in men 9% in women
167
Alcohol dependence prevalence
6% men 2% women
168
Lifetime prevalence use of illicit drugs in Europe
```
Cannabis22.5%
Cocaine4.1%
Amphetamine3.7%
Ecstasy3.3%
Opioids*0.5%
```
169
Which of the following should be avoided with low blood pressure in alcohol detox?
Lofexidine
170
What is used for ultra rapid opiate detoxification?
Naloxone
171
What is most suggestive of a chronic alcohol problem?
Multiple spider naevi
172
What is codependency in addictions?
Codependency refers to a situation whereby a person becomes psychologically dependent on the behaviour of an 'addict'.
The issue is significant as the codependent person may encourage (not necessarily consciously) the addiction and perpetuate it so as to protect their role
173
What is enabling behaviour in addictions?
Enabling behaviour occurs when a codependent person, helps or encourages an addict to continue using drugs, either directly or indirectly. An examples could be a spouse giving the addict money to buy drugs.
174
What are alcoholic blackouts? What's the implication on long term cognitive impairment?
refers to transient memory loss induced by intoxication (anterograde amnesia). There is no associated loss of consciousness. These blackouts are not pathognomic of alcohol
Blackouts do not predict long term cognitive impairment
175
What illusion does PCP create?
ability to induce the illusion of euphoria, omnipotence, superhuman strength, and social and sexual prowess.
176
What's the best management for PCP intoxication?
Benzos
177
Percentage of general population who drank alcohol in
| the last week in the UK?
67% men; 53% women
178
Percentage of adults who drank above the recommended
limits among those who drank alcohol in the last week
55% men (24% of general population); 53%
| women (18% of general population)
179
Percentage of school pupils (aged 11-15) who had drunk
alcohol at least once
43%
180
Patients presenting to primary care that consume alcohol
at harmful or hazardous levels
20%
181
Annual prevalence of hazardous drinking (AUDIT score
| >= 8) in UK households
38% of men; 15% of women;
27% of White
adults,
18% of Black adults
8% South
Asian adults
182
Peak age of hazardous drinking
16 to 19 (women); 20-24 years (men)
183
Prevalence of alcohol dependence
74 per 1,000 overall; 119 per 1,000 men and
| 29 per 1,000 women.
184
Number of all hospital attendees/admissions that are
| alcohol related
1 in 16 hospital admissions (Pirmohamed,
2000);
1 in 6 A&E attendees (this rises to 8
in 10 during peak hours) (HEA, 1998).
185
Age-specific use patterns in alcohol dependent people
Age at first drink (13-15),
age at first
intoxication (15-17)
age at first
‘problem’ related to alcohol (16-22) is
essentially the same as the general
population for alcohol dependent patients.
But the age at death is around 60 years –
very premature.
186
Alcohol use during pregnancy
One in 10 pregnant women drank in the
| last week
187
Percentage of UK adults (16 to 59) who took an illicit
| drug in the last year
1 in 12 (8.3%);
frequent users i.e.
>once/month = 2.8%
(Cannabis (6.4%)
followed by powder cocaine (1.9%) and
ecstasy (1.3%))
188
Percentage of young adults (16 to 24) taking any drug
| in the last year in the UK
1 in 6 (16.3%); frequent users = 5.1%
189
Percentage of adults aged 16 – 59 had taken a Class A
| drug in the last year
2.6%
190
Percentage of school pupils who took an illicit drug in
| the last year in the UK
12% (raises to 17% if all past exposure s are
| considered)
191
Percentage of drug users in the last year who use
| multiple substances
```
61% when alcohol is also included; 7% for
other drugs (not alcohol)
```
192
The most commonly reported age for first taking
| drugs.
Cannabis - 16 years; powder cocaine and
| ecstasy - 18 years
193
Average duration of drug use among regular users.
Cannabis - 6.2 years; powder cocaine (4.4
years) or ecstasy (3.9 years)
194
What's the ICD10 has a diagnostic code for ‘harmful use’ of alcohol mean?
the actual damage is caused to the
drinker physically or mentally, but he has no dependence pattern (yet).
195
What are Cloninger’s classification of alcohol dependence?
```
Type 1
Milieu limited
Males and females
Loss of control
No strong family history
Not much criminality
Starts >25years
```
```
Type 2
Male limited
Males usually
Inability to abstain
Strong heritability
Antisocial traits high
Starts <25 years
```
196
Jellinek’s classification of alcohol dependence
Alpha α Psychological dependence; undisciplined not progressive; no
withdrawal; major problems are in interpersonal domain only
Beta β Physical damage but no dependence
Gamma γ Loss of control plus physical dependence. Withdrawal seen; earlier
stages are similar to alpha – most common among AngloSaxons
Delta δ No loss of control but unable to abstain e.g., in France this may be
socially accepted – no disapproval or interpersonal problems
Epsilon ε Dipsomania – binges and bouts
197
Pharmacokinetics of alcohol
Intercalates into the fluid cell membrane; decreases NMDA sensitivity;
increases GABA sensitivity; downregulates calcium channels; upregulates nicotine receptor gated
sodium channels.
198
Pharmacokinetics of alcohol
Intercalates into the fluid cell membrane; decreases NMDA sensitivity;
increases GABA sensitivity; downregulates calcium channels; upregulates nicotine receptor gated
sodium channels.
199
Prevalence of heroin use in the UK
| M:F
The current prevalence of heroin use in the UK is around 1%
| (male-to-female ratio of 2:1), with most treatment seekers being in their 20s
200
Which types of receptors are important in opioid physiology?
3 receptors are important in opioid physiology. Mu (μ), kappa (κ) and delta (δ) – all three are G coupled protein
201
What's the half life of heroin?
<3 minutes
202
What's the potency of Buprenorphrine compared to Morphine?
40 times more potent at
receptor level, but a
partial agonist
203
Symptoms of benzo intoxication
Slurred speech, incoordination, unsteady gait,
nystagmus , impairment in attention or memory, stupor or coma
behavioural changes
such as inappropriate sexual or aggressive behaviour, mood lability, and impaired
judgment.
204
What is flumazenil?
Flumazenil is a specific benzodiazepine antagonist used in A&E/ICU to reverse the effects of the benzodiazepines
205
Mechanism of action of amphetamines?
Amphetamines block catecholamine (DA & NEN especially) reuptake and
stimulate their release from vesicles.
206
Mechanism of action of cocaine?
It has a potent dopamine reuptake blockade
| effect
207
Physical adverse effects of cocaine use
```
Nasal perforation on snorting.
Nonhemorrhagic cerebral infarctions.
Subarachnoid, intraparenchymal, and intraventricular hemorrhages.
TIAs
Seizures (3 to 8% of A&E visits)
Myocardial infarctions and arrhythmias
```
208
Symptoms of caffeine intoxication
Caffeine intake in excess of 250 mg (>2-3 cups at once) can produce restlessness,
nervousness, excitement, insomnia, flushed face, diuresis, gastrointestinal disturbance, muscle
twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of
inexhaustibility and psychomotor agitation
209
Half life and peak concentration of caffeine
The half-life of caffeine in the human
body is 3 - 10 hours and the time of peak concentration is 30 to 60 minutes.
210
Does caffeine cross the blood-brain barrier?
Caffeine readily crosses the blood-brain barrier and
211
Nicotine withdrawal symptoms
The features of withdrawal reaction
are dysphoric or depressed mood, insomnia, irritability, frustration, or anger, anxiety,
difficulty concentrating, restlessness, decreased heart rate and increased appetite or weight
gain.
These symptoms begin a few hours after the last cigarette, peak 2 to 3 days after
quitting, and become less intense over 1 to 3 weeks. Smokers also report cravings for
cigarettes, which can last for a longer period
212
Which hepatic enzyme is nicotine known to stimulate?
CYP1A2
213
What's the mechanism of action of nicotine?
Nicotine stimulates central nicotinic acetylcholine receptors and improves alertness.
214
What's the mechanism of action of inhalants?
Inhalants generally act as CNS depressants
215
What is the common factor model for substance abuse and psychiatric illness?
Genetic vulnerability, antisocial personality traits and low social status (predisposing factors)
216
What is the secondary use model for substance abuse and psychiatric illness?
Patients use substances to alleviate dysphoria or medicate symptoms and reduce social isolation
217
What is the supersensitivity model for substance abuse and psychiatric illness
Mental ill patients are unusually sensitive to negative social and health consequences of substance exposure
218
What is the secondary illness model for substance abuse and psychiatric illness (popular with lay public)?
Substance misuse leads to mental illness by a mechanism similar to kindling or behavioural sensitisation
219
What is pathological intoxication?
- a severe behavioural reaction that develops rapidly after consumption of a small amount of alcohol
- includes confusion, hallucinations, high psychomotor agitation, impulsive/aggressive behaviour
- lasts a few hours, usually terminates in prolonged sleep
220
What is primary alcoholic dementia?
Persistent dementia attributable to the direct toxic effect of alcohol on the brain (contested diagnosis)
221
Other than clinical assessment what is the most valuable diagnostic tool for Wernicke's?
MRI (93% specificity, 53% sensitivity)
222
How would you manage a healthy/uncomplicated patient with alcohol dependence during detox?
minimum 300mg PO thiamine
223
How would you manage a patient at high risk of Wernicke's during detox?
250mg IM/IV Pabrinex for 3-5 days
224
How quickly do signs/symptoms of Wernicke's respond to treatment?
Ophthalmoplegia = hours
| Cognitive impairment = longer
225
Other than anterograde amnesia, what are the features of Korsakoff's?
Confabulation and apathy
| Relative preservation of attention + procedural and working memory
226
Where are lesions found in Korsakoff's?
Dorsomedial thalamus
227
What is alcohol related cerebellar degeneration?
Degeneration of purkinje cells in the cerebellar cortex due to alcohol induced damage
228
What percentage of chronic alcoholic suffer with cerebellar degeneration?
40%
229
What are the symptoms of cerebellar degeneration?
Limb ataxia, dysarthria, nystagmus (rare)
230
What are the signs/symptoms of hepatic encephalopathy?
Metabolic flapping tremor (asterixis), hyperreflexia, extensor plantar respones (babinski +ve), altered sensation
231
What is hepatocerebral degeneration?
Residual neurological deficit post encephalopathy
| Includes: tremor, choreoathetosis, dysarthria, ataxia and dementia
232
What are the clinical manifestations of central pontine myelinosis?
Pain sensation in limbs, bulbar palsy, quadriplegia, disordered eye movements, vomiting, confusion, coma, locked in syndrome
233
Other than chronic alcoholism, which other conditions can lead to CPM?
CLD i.e. Wilson's, malnutrition, anorexia, burns, cancer, Addison's, severe electrolyte disturbance
234
What is the pathophysiology of alcoholic pancreatitis?
Calcium salts are chelated by free fatty acids generated by lipase following damage to the pancreas. These are deposited in the retroperitoneum resulting in back pain and hypocalcaemia. Hypoalbuminaemia and hypomagnaesaemia may also feature.
235
How does pancreatitis induced hypocalcaemia affect PTH levels?
They may be normal, suppressed or elevated
236
How should pancreatitis induced hypocalcaemia be treated?
Parenteral calcium and magnesium replacement
| Assess Vit D status to rule out malabsorption
237
What are the features of stimulant induced psychosis?
Similar to schizophrenia (particular paranoia)
```
Important differences include:
absence of prominent negative symptoms
predominance of visual hallucinations
associated hyperactivity
generally appropriate affect
disinhibited sexual behaviours
confusion and incoherence
almost no formal thought disturbance
```
238
How is stimulant induced psychosis diagnosed?
Rapid resolution of symptoms (within a few days) or positive drug screen
239
If you were going to treat a patient with stimulant induced psychosis what would you use?
Short term haloperidol or other antipsychotic
240
Name two cannabis related syndromes
1. Hemp insanity (florid psychosis after high doses of high potency cannabis)
2. Amotivational syndrome (associated with long term heavy use - loss of motivation to persist in tasks requiring prolonged effort/attention)
241
What symptoms are common in children born to mothers who actively consume cannabis during pregnancy?
Mild attentional problems and impulsivity
242
Name two hallucinogen related syndromes
1. 'Bad trip' (similar to acute panic reaction but longer duration, can produce true psychotic symptoms, usually stops when effects of drug wear off)
2. Hallucinogen persisting perception disorder (re-experiencing perceptual symptoms following cessation of hallucinogen use i.e. geometric hallucinations, false perceptions of movement in periphery, flashes or intensified colours)
243
What can trigger Hallucinogen persisting perception disorder?
Emotional stress, sensory deprivation, use of another psychoactive substance
244
What are the risk factors for alcoholism?
Sociocultural factors: disruption of family structure, domestic violence, social networks that use alcohol, recent immigration, small area deprivation
Genetic factors: specific gene loci
Biomarkers: low 5HT, 5HIAA, MAO
245
What are the sociocultural risk factors for smoking tobacco?
Low school achievement, young among peer cohort, poorer relationship with family, low household income
246
What are the sociocultural risk factors for using illicit substances?
Peer drug use, single parent, homelessness, poor educational attainment, neighbourhood disadvantage, unemployment
247
Dextromethorphan can cause a false positive drug screen result for which illicit substance?
PCP
248
What is the advantage of using a symptom triggered detox regimen (alcohol)?
Faster control, fewer total BZDs needed, avoids oversedation
249
What is the first line alternative to BZDs in alcohol detox regimens?
Carbamazepine
250
12 step AA facilitatation programme
The 12 steps are
1. Accept powerlessness in front of alcoholism.
2. Admit only a Greater power can help
3. Make a decision to turn our to the care of God as you understand Him
4. Make a searching and fearless moral inventory.
5. Admit wrongs done to others.
6. Become entirely ready for removal of these defects.
7. Ask Him to help now.
8. Be willing to make amends to all
9. Make direct amends where possible
10. Continue personal inventory.
11. Prayer and meditation.
12. Practice and preach.
251
How should opioid overdose be managed
1. Airway (A-E)
| 2. Naloxone
252
What harm-reduction advice can be given to patients who use opioids?
1. Don't use when alone
2. Don't combine with other drugs/ETOH
3. Avoid IV
4. If using IV: inject in direction of blood flow/rotate injection sites/ensure complete dissolution before injection/new syringe and needle each time/use sterile water/avoid lemon juice/never share equipment (risk of emboli and infection)
253
What drug can be used to prevent relapse in opioid dependence?
Naltrexone (small evidence base)
254
NICE guidelines for opioid detox
For all patients who are opioid dependent and have expressed an informed choice to become
abstinent, services should:
o Offer detoxification readily;
o Provide detailed information about detoxification especially the withdrawal
experience, management approaches, loss of opioid tolerance on successful
detoxification and so the risk of intoxication rises significantly.
o Offer buprenorphine or methadone as first line treatment, with due consideration to
service user’s preference.
o Detoxification should normally be started with the same medication as being used for
maintenance in patient.
o Consider lofexidine, especially for those with mild or uncertain dependence, but
warn patients that this necessitates the use of adjunct medications to manage
withdrawal symptoms such as nausea, vomiting and shivering
o Lofexidine detox outcomes are no better than for buprenorphine or methadone;
o Do not routinely use drugs such as benzodiazepines, minor analgesics, or
antidiarrhoeals to manage opioid withdrawal symptoms.
255
Offer a community based detoxification programme routinely, except when:
Previous failure of community detoxification.
Significant additional physical or mental health problems
Polydrug detoxification
Significant social problems
256
How long should NRT be continued after cessation?
2 weeks
257
Is there any difference in the efficacy of different NRT preparations?
No (but higher dosage is better for heavier smokers)
258
Can multiple NRT products be used together?
Yes
259
Which NRT product has the best compliance?
Patch
260
How does nicotine release differ dependent on preparation?
Patch: slowest but most consistent release
Nasal spray: fastest release (blood nicotine levels peak after 5-10 minutes)
Gum/inhaler: peak at 20 minutes
(smoking quicker that all of the above)
261
Is NRT safe for patients with CVD?
Yes (if stable)
262
How long should be left after an unsuccessful attempt at smoking cessation using pharmacological intervention before trying again?
6 months
263
What percentage of pathological gamblers have co-morbid substance misuse?
30-50%
264
What are the 5 types of internet addiction?
1. cybersexual
2. cyberrelationship
3. net compulsion i.e. gambling, shopping
4. information overload i.e. database searching
5. gaming addiction
*Internet addiction only features in DSMV (not ICD)
265
What is oniomania?
Compulsive buying characterised by behaviour that is uncontrollable, markedly distressing, time consuming and/or resulting in family/social/vocational/financial difficulties
Must not only occur in context of hypo/mania
(not recognised in either diagnostic manual)
266
Why is anabolic steroid abuse classified under disorders of physiology in ICD-10?
Because it is not psychoactive in nature
267
What are the 3 patterns of anabolic steroid abuse?
1. Cycling
2. Stacking
3. Pyramiding
268
What are the unwanted effects of anabolic steroid use?
```
Aggression/violence
Psychosis
Mania
Depression
Endocrine abnormalities resulting in acne (50% of people), testicular atrophy +/or gynaecomastia (1/3 of people)
```
269
What are the different types of legal highs?
1. Stimulant like i.e. mephedrone (AE = serotonin syndrome, psychosis, hyperthermia, CV symptoms)
2. Psychedelic-like i.e. DMT
3. Cannabis-like i.e. spice (AE = paranoia, psychosis, intense anxiety, seizures)
4. Benzomimetic i.e. flubromazepam (AE = respiratory depression, withdrawal seizures)
5. Dissociative anaesthetic-like i.e. mexxy (AE = headache, psychotic symptoms, nausea, cognitive impairment)
270
What is the most common non-genetic cause of LD?
Foetal Alcohol Syndrome
271
What are the features of FAS?
Intellectual impairment, facial dysmorphia, disruptive behaviour
272
Can medications to aid alcohol abstienence be used in pregnancy?
No - offer psychosocial support instead
273
What are the risks of opiate use during pregnancy?
Infection secondary to injecting, drug induced stillbirth, premature birth, antenatal complications e.g. haemorrhage, low birth weight, microcephaly, neonatal abstinence syndrome
274
Is heroin or methadone more likely to induce withdrawal in the newborn?
Methadone (60-80% more likely)
275
What impact does maternal cocaine use have on newborns?
Small for Gestational Age
| Microcephaly
276
What impact does maternal cannabis use have on newborns?
Low Birth Weight (2x risk)
| ?negatively affects neurodevelopment
277
What are the features of neonatal alcohol withdrawal syndrome?
Onset 3-12 hours after birth
Hyperactivity, irritability, poor sucking, tremors, seizures, poor sleeping patterns, sweating, hyperphagia
May be followed by FAS
278
What are the features of neonatal barbiturate withdrawal syndrome?
Irritability, severe tremors, hyperacusis, excessive crying, diarrhoea, vomiting, increased tone, disturbed sleep
279
What are the features of neonatal cannabis withdrawal syndrome?
Fine tremors, hyperacusis, prominent Moro reflex
Usually mild and does not require treatment
280
What are the features of neonatal nicotine withdrawal syndrome?
Fine tremors, subtle neonatal behaviours i.e. poor self-regulation and increased need for handling
281
What are the features of neonatal opiate withdrawal syndrome?
Onset 24-48h after birth but may not appear for 3-4 days
Hyper-irritability, GI dysfunction, respiratory distress, vague autonomic symptoms (i.e. yawning, sneezing, mottling, fever), high pitched cry, increased tone, exaggerated reflexes, loose stools leading to electrolyte disturbance and diaper dermatitis
282
What are the features of neonatal antidepressant withdrawal syndrome?
Jitteriness, respiratory distress
More commonly observed with short acting SSRIs i.e. paroxetine
283
What are the features of neonatal benzodiazepine withdrawal syndrome?
Neonatal benzodiazepine withdrawal syndrome presents with hypotonia and lethargy, and may persist from hours to months after birth
284
Ebstein's anomaly is sometimes associated which drug other than lithium?
Diazepam
285
What is the lifetime prevalence of psychiatric disorder in long term cocaine users?
50-80%
286
What score on Short Alcohol Withdrawal Scale means need for pharmacological treatment?
12
287
How long can cocaine be detected in urine drug screen?
2-4 days
288
How long can heroin be detected in urine drug screen?
Up to 3 days
289
Which receptor does caffeine act on?
Adenosine (antagonis
290
What's the common cause of death due to GBH?
Aspiration pneumonia
291
According to DSM 4 consumption above which dose is considered caffeinism?
250mg
292
What's a potentially dangerous side effect of clinidine when used for treating opioid dependence?
Hypotension
293
What's abstinence violation?
"I had a drink therefore I am a drinker again"
294
Tolerance is least likely to develop for which symptom of amphetamine use?
Increased blood pressure
295
% of patients taking benzos for a year that develop dependence?
40%
296
1 year prevalence of substance misuse according to Steel et al
1 in 25
297
Following sudden cessation of alcohol on a dependent patient, the risk of seizure is high during?
First 24 hours
298
A man after completing his opioid detoxification is highly motivated to remain on treatment and wants advice about maintaining it. Which of the following drugs is best suited in this situation?
Naltrexone
299
Which drug is related to anandamide?
Cannabis
300
Drugs which interfere with ionotropic receptors or ion channels
Alcohol, nicotine, benzodiazepines, ketamine
301
Drugs which interfere with G coupled receptors
Opioids, cannabinoids, y-hydroxybutyrate (GHB)
302
Drugs that target monoamine transporters
Amphetamine, ecstasy, cocaine
303
Apart from hallucinogens the drug capable of producing bad trips and persistent flashbacks is
Cannabis
304
Chronic harmful effects of cocaine use
possible neuro-toxicity, hepatotoxicity, and possible chronic cognitive impairment
305
Signs of inhalant intoxication
dizziness, nystagmus, incoordination, slurred speech, unsteady gait, lethargy, depressed reflexes, psychomotor retardation, tremor, generalized muscle weakness, blurred vision or diplopia, stupor or coma and euphoria
A recent inhalant user may have rashes around nose and mouth; unusual breath odours; the residue of the inhalant substances on body or clothes; and signs of ocular and oropharyngeal irritation
306
one year prevalence of clinical depression among those who have alcohol dependence
25-30%
307
The prevalence of alcohol related problems in a community is linked to the
Per capita alcohol consumption
308
long term cocaine users arelikely to have abnormalities in which cognitive domain?
sustained attention
309
Which nutrient when deficient would result in refractoriness when treating Wernicke's encephalopathy?
Magnesium
310
What are the physiological disturbances associated with long-term use of ketamine?
Renal membrane nephropathy
311
What are the physiological disturbances associated with long-term use of amphetamine?
Hypertension
312
What are the physiological disturbances associated with long-term use of heroin?
Renal membrane nephropathy
